The nurse will be using the Braden Scale with each admit to the longterm care center. Which of these will be utilized in a Braden Scale assessment? (Select all that apply.)
Sensory perception
Age
Friction and shear
Nutrition
Mental state
Correct Answer : A,C,D
Choice A reason: Sensory perception is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client can respond to pressurerelated discomfort or pain. Sensory perception can be affected by factors such as level of consciousness, spinal cord injury, or neuropathy. Sensory perception can influence the risk of pressure injuries, as clients with impaired sensory perception may not be able to feel or report the pressure, or change their position to relieve the pressure.
Choice B reason: Age is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Age is a demographic variable that can be associated with other factors that affect the risk of pressure injuries, such as skin condition, mobility, or comorbidities. However, age itself is not a factor that is measured or scored in the Braden Scale assessment.
Choice C reason: Friction and shear is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's skin is exposed to rubbing or sliding forces. Friction and shear can be affected by factors such as bed linens, transfers, or repositioning. Friction and shear can influence the risk of pressure injuries, as they can damage the skin and underlying tissues, or reduce the blood flow and oxygen delivery to the skin and tissues.
Choice D reason: Nutrition is one of the six subscales that will be utilized in a Braden Scale assessment, because it measures the degree to which the client's intake of food and fluids meets the body's needs. Nutrition can be affected by factors such as appetite, dentition, or swallowing. Nutrition can influence the risk of pressure injuries, as it can affect the skin integrity, wound healing, and immune function of the client.
Choice E reason: Mental state is not one of the six subscales that will be utilized in a Braden Scale assessment, because it is not a direct or independent predictor of pressure injury risk. Mental state is a psychological variable that can be associated with other factors that affect the risk of pressure injuries, such as sensory perception, mobility, or activity. However, mental state itself is not a factor that is measured or scored in the Braden Scale assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Psoriasis is a skin abnormality that causes patches of thick, red skin with silvery scales, usually on the elbows, knees, scalp, lower back, or genitals. Psoriasis is a chronic, inflammatory, autoimmune condition that affects the life cycle of skin cells, causing them to build up rapidly on the surface of the skin. Psoriasis can cause itching, burning, pain, or bleeding.

Choice B reason: Rosacea is a skin abnormality that causes redness, flushing, swelling, or pimples, usually on the face, especially the cheeks, nose, chin, or forehead. Rosacea is a chronic, inflammatory, vascular condition that affects the blood vessels and sebaceous glands of the skin. Rosacea can cause sensitivity, stinging, or dryness.
Choice C reason: Scabies is a skin abnormality that causes small, red bumps, blisters, or burrows, usually on the hands, wrists, feet, ankles, or genitals. Scabies is a contagious, parasitic infection that is caused by tiny mites that burrow into the skin and lay eggs. Scabies can cause intense itching, especially at night.
Choice D reason: Stasis dermatitis is a skin abnormality that causes swelling, redness, scaling, or ulcers, usually on the lower legs or ankles. Stasis dermatitis is a chronic, inflammatory condition that results from poor blood circulation in the veins of the legs, causing fluid to leak into the surrounding tissues. Stasis dermatitis can cause pain, itching, or infection.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: "I will monitor my nutrition and fluid status." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Monitoring nutrition and fluid status is an important selfcare measure for people with HIV, as it can help maintain the immune function, prevent dehydration, and promote healing. People with HIV should eat a balanced and varied diet, drink enough water, and avoid foods or drinks that can cause diarrhea, nausea, or vomiting.
Choice B reason: "Because I have HIV, that means I'm an AIDS patient." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having HIV does not mean that one has AIDS, but rather that one is at risk of developing AIDS. HIV is the virus that causes AIDS, which is the most advanced stage of the infection. AIDS is diagnosed when the CD4+ Tcell count drops below 200 cells per microliter of blood, or when the person develops one or more opportunistic infections or cancers. People with HIV can delay or prevent the progression to AIDS by taking antiretroviral drugs, which can suppress the viral load and improve the immune function.
Choice C reason: "I can still have unprotected intercourse with my partner since he doesn't have HIV." is a statement that requires further teaching or clarification, because it is incorrect and misleading. Having unprotected intercourse with a partner who does not have HIV is not safe or advisable, as it can expose the partner to the risk of contracting HIV. HIV is transmitted through sexual contact, as well as through blood, semen, vaginal fluid, or breast milk. People with HIV should use condoms or other barrier methods during intercourse, regardless of the HIV status of their partner. People with HIV should also inform their partner about their infection, and encourage them to get tested and treated if needed.
Choice D reason: "I need to ensure that I place my needles in a proper needle disposal container." is not a statement that requires further teaching or clarification, because it is correct and appropriate. Placing needles in a proper needle disposal container is an important infection prevention measure for people with HIV, as it can prevent the accidental or intentional reuse or sharing of needles, which can transmit HIV or other bloodborne diseases. People with HIV should use new and sterile needles for injections, and dispose of them in a punctureresistant and leakproof container, which can be obtained from a pharmacy, clinic, or health department.
Choice E reason: "I can spread this through contact with surfaces, so I need to wear gloves in public." is a statement that requires further teaching or clarification, because it is incorrect and exaggerated. Spreading HIV through contact with surfaces is not possible or likely, as the virus does not survive long outside the body, and is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Wearing gloves in public is not necessary or advisable, as it can create a false sense of security, stigma, or discrimination. People with HIV should practice good hygiene, such as washing hands, covering coughs, and cleaning wounds, but they do not need to wear gloves or other protective equipment in public.
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